| NPI | 1659704500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 016763) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00316000) |
| 363A00000X Physician Assistant (Licence: CA PA51247) | |
| Enumeration Date | 2013-08-14 |
| Last Update Date | 2015-02-12 |